Healthcare Provider Details

I. General information

NPI: 1437534914
Provider Name (Legal Business Name): JEWELL THOMPSON M.S, QMHP, CADC, PSS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/24/2015
Last Update Date: 07/27/2024
Certification Date: 06/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

436 E 36TH ST
CHARLOTTE NC
28205-1030
US

IV. Provider business mailing address

2166 GOLD HILL RD STE 4
FORT MILL SC
29708-9351
US

V. Phone/Fax

Practice location:
  • Phone: 704-819-0464
  • Fax: 803-973-0207
Mailing address:
  • Phone: 704-819-0464
  • Fax: 803-973-0207

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number2023-10462-01
License Number StateNC
# 3
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number25110
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: